HEALTH PROMOTION What is Health Promotion all about?

HEALTH PROMOTION

What is Health Promotion all about?

What is Health Promotion all about?

• It is the process of enabling people to increase control over and improve their health. (Ottawa H.P. Charter).

• It is a process which empowers families and communities to improve their quality of life, and achieve and maintain health and wellness.

• It emphasizes not only prevention of disease but the promotion of positive good health.

What is Health Promotion all about?

• It is a positive concept emphasizing personal, social, political and institutional resources, as well as physical capacities.

• Health promotion is any combination of health, education, economic, political, spiritual or organizational initiative designed to bring about positive attitudinal, behavioral, social or environmental changes conducive to improving the health of populations.

• Health promotion is directed towards action on the determinants or causes of health

• Health promotion, therefore, requires a close co-operation of sectors beyond health services, reflecting the diversity of conditions which influence health.

• Government at both local and national levels has a unique responsibility to act appropriately and in a timely way to ensure that the ‘total’ environment, which is beyond the control of individuals and groups, is conducive to health.

What is Health Promotion all about?

Definitions of health promotion

• “Any combination of health education and related organizational, economic and political interventions designed to facilitate behavioral and environmental changes conductive to health”. (Green LW 1979)

• "Health promotion is the science and art of helping people change their lifestyle to move toward a state of optimal health.  Optimal health is defined as a balance of physical, emotional, social, spiritual, and intellectual health.  Lifestyle change can be facilitated through a combination of efforts to enhance awareness, change behavior and create environments that support good health practices.  Of the three, supportive environments will probably have the greatest impact in producing lasting change".  (American Journal of Health Promotion, 1989,3,3,5)

Health promotion …….

“is the process of enabling people to increase control over and to improve their health” (Ottawa Charter ’86)

“involves the facilitation of skills in individuals and change in environments which impact positively on health” (VicHealth 2005)

“is everyone’s business” (CEO DHCS 2004)

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The key principles of health promotion as determined by WHO are as follows:

Health promotion involves the population as a whole in the context of their everyday life, rather than focusing on people at risk from specific

diseases.

PRINCIPLES OF HEALTH PROMOTION

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Health promotion is directed towards action on the determinants or cause of health. This requires a close co-operation between sectors beyond health care reflecting the diversity of conditions which influence health.

PRINCIPLES OF HEALTH PROMOTION

9

Health promotion aims particularly at effective and concrete public participation. This requires the further development of problem-defining and decision-making life skills, both individually and collectively, and the promotion of effective participation mechanisms.

PRINCIPLES OF HEALTH PROMOTION

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Health promotion combines diverse, but complementary methods or approaches including communication, education, legislation, fiscal measures, organisational change, community change, community development and spontaneous local activities against health hazards.

PRINCIPLES OF HEALTH PROMOTION

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Health promotion is primarily a societal and political venture and not medical service, although health professionals have an important role in advocating and enabling health promotion.

PRINCIPLES OF HEALTH PROMOTION

Health Promotion includes …

• Promoting healthy lifestyles.• Getting people involved in their own

health care.• Creating an environment that makes

it possible to live a healthy life. • Recognition of lifestyle diseases as

major causes of illness and death.• Strengthening community

participation.

• Build healthy public policy• Create supportive environments• Strengthen community action• Develop personal skills• Re-orient health services

The Ottawa Charter for Health Promotion

Examples of preventable health problems related to lifestyle

• Chronic non-communicable diseases such as diabetes and hypertension. These are major causes of illness and death. They are related to… – Overweight and obesity.– Unhealthy diet.– Insufficient physical activity.

• HIV/AIDS is related to unsafe sexual lifestyle, and causes many deaths.

Intersectoral approach Health Promotion brings together many

sectors to work towards the achievement and maintenance of health and wellness.– The Health sector alone cannot achieve a

healthy society. – All sectors, both government and non-

government, need to work together. – Health Promotion can provide the link

between the various sectors.– Within Health the various disciplines also need

to work together towards wellness.

Some non-health sectors with an input into Health Promotion…

• Education/ schools• Agriculture• Community Services• Sports• Media• Non-Governmental Organizations (NGO’s)• Community groups• Youth• Private sector

Health sectors with an input into Health Promotion

• Environmental Health• Nutrition• Community nursing• Mental Health• Dental• Epidemiology• Hospital (secondary) care• School of Nursing• Occupational therapy

Some other sectors which are important

• Legal• Public Works• Housing• Water Authority• Religious Council• Alternative medicine

Formulating healthy public policy

• Promotes healthy policies in all sectors , eg healthy workplaces, schools, homes, buildings, villages and communities.

• Health aspect should be thought of and included in the policies of the various sectors.

• Health Policies should also emphasize the prevention and promotion.

Healthy public policy is a pre-requisite for successful health promotion.

A Healthy Public Policy is characterized by a concern for health and equity and an accountability for health impact.

Health should be made a priority item on the agenda of policy-makers in all sectors.

Policy-makers should be made aware of the health consequences of their decisions. They should create pro-health policies, whether in the area of development, legislation, taxation etc.

Formulating healthy public policy

According to the Adelaide Conference (1988), “The main aim of HPP is to create a supportive environment to enable the people to lead healthy lives. Healthy choices are thereby made possible and easier for citizens”.

All relevant government sectors like agriculture, trade, education, industry and finance need to give important consideration to health as an essential factor during their policy formulation.

Formulating healthy public policy

Reorienting health services

Since lifestyle is linked to many of today’s health problems, prevention and promotion should decrease the burden on secondary (curative) health care.– Greater emphasis and resources placed on

health promotion and primary health care.– Less emphasis on purchase of high tech

equipment for secondary health care. – Equity in health care.

Shift of emphasis from provision of curative services.

Health care system must be equitable and client-centered.

May necessitate reengineering and organizational change, especially in the areas of professional education and training, management, recruitment and deployment of health personnel, and planning, development and delivery of services,

Reorienting health services

Empowering communities to achieve well-being

• Involvement of the community in health decisions, a multisectoral and participatory approach.

• Provide communities with the information and tools to take actions to improve health and well-being.

According to the Ottawa Charter, “health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health”.

There are many ways of defining community. Factors used are geography, culture and social stratification.

Community action is any activity undertaken by a community in order to effect change (including voluntary and self-help services).

Empowering communities to achieve well-being

Community participation covers a spectrum of activities At the low end, it may be token participation in the form of consultation or endorsing plans drawn up by the health authorities.At the high end, it may be in the form of ‘people power’ where they have full say in identifying needs, setting priorities, planning strategies and activities and implementing the programme.

Empowering communities to achieve well-being

Full community participation occurs when communities participate in equal partnership with health professionals as stakeholders in setting the health agenda.

A Definition (Rifkin et al. 1988)Community participation is a social process whereby groups with shared needs living in a defined geographic area actively pursue identification of their needs, take decisions and establish mechanisms to meet these needs

Empowering communities to achieve well-being

According to the Jakarta Declaration (1997), “health promotion improves both the ability of individuals to take action, and the capacity of groups, organizations or communities to influence the determinants of health”.

Empowerment is an important strategy, based on the notion that health is significantly affected by the extent to which one has control or power over one’s life.

Empowering communities to achieve well-being

Creating supportive environments

• Healthy physical, social and economic environment.

• All development activities should aim for a healthy environment – healthy buildings, roads, workplaces, homes, surroundings and schools.

A supportive environment is essential for health.

Supportive environments cover the physical, social, economic, and political environment.

Supportive environments encompass where people live, work and play.

Everyone has a role in creating supportive environments for health.

Creating supportive environments

Developing /increasing personal health skills

• Information and education for personal and family health.

• Take account of values, beliefs and customs of the community.

• Continuous process at all stages of life.• Guided and supported in developing skills

(not imposed on them).• Build on existing knowledge and attitudes.

Strategies for empowering the community include leadership training, learning opportunities for health, and access to resources including material and fundingEmpowerment helps people to identify their own needs and concerns, and gain the power, skills and confidence to act upon them. It is a bottom-up strategy which requires the health promoter to act as a facilitator and catalyst for change.

Developing /increasing personal health skills

Skills which can promote an individual’s health include those pertaining to identifying, selecting and applying healthy options in daily life.

Health education is life-long, so that people can develop the relevant skills to meet the health challenges of all stages of life, and to be able to cope with chronic illness and disabilities.

Health education should be conducted in all settings.

Developing /increasing personal health skills

Building alliances with special emphasis on the media

• Media key players, influence on health of people.

• Partnership with media ensures their collaboration and that correct information is passed on.

• Free flow of information both ways, on matters vital to health.

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Building a healthy public policy

Creating supportive

environments

Developing personal skills

Strengthening community

action

Reorientating health

services

IMPORTANT AREAS FOR CONSIDERATION IN HEALTH PROMOTION

Health promotion policy and practice

Evidence based interventions  

EVIDENCE

CURRENT HEALTH PROMOTION POLICY AND PRACTICE Evidence Based

Interventions

Figure 1. Increasing the use of health promotion evidence in policy and practice

Capacity Building framework: key action areas

Organisational Development• Workforce Development• Resources• Partnerships• Leadership

NSW Health. 2001 on NSW website

10 Key Action Areas for Health Promotion

(Ottawa Charter and Jakarta Declaration)

• Build healthy public policy• Create supportive environments• Strengthen community action• Develop personal skills• Reorient health services towards primary health

health care• Promote social responsibility for health• Increase investment for health development to

address social inequalities leading to poor health• Consolidate and expand partnerships for health • Strengthen communities and increase

community capacity to empower the individual• Secure an infrastructure for health promotion

.Build Healthy Public Policy

• Both within and outside the health sector (social determinants of health)

• Approaches such as legislation, fiscal measures, taxation and organisational change.

• OHS, Council bylaws, school sun care

• Policy to influence culture e.g. bullying

Create supportive environments

• Create environments (work, home and leisure) that support healthy living?

• e.g. food choices, suncare, smoke free

.Strengthen

community actionEnable and empower communities, provide resources so they actively participate in health decisions which leads to better health outcomes. They can apply those skills to other situations themselves need to determine what their needs are and how they best can be met.

• Community development.• Capacity building.

Reorient heath services

• Aim for a balance between health promotion and treatment services?

• How can we work with other sectors whose work impacts on health?

• Include health promotion in job descriptions, a designated role.

Develop Personal Skills (the one we are most familiar with)

• Provide information, education and skills.

• Those who gain skills are often the least likely to need them

• So be creative and reach others e.g. display or health screening or other activity – those who you need to reach may not attend/be able to read etc

• Build skills at all levels - support others to work in a health promoting way.

The health promoting way of working……..

• Work with the community to identify priorities• Support local initiatives • Find out what is already happening• Find out what people know and what they

think is important• Share information• Assist with skills development • Assist with research & information collection• Help to plan community action• Provide or assist to locate resources if needed

Spectrum of health promotion interventions

Strive to develop a mix of evidence based health promotion interventions

• with a balance of interventions at both an individual and population level

• that meet the priority outcomes

Support these with capacity building strategies (skills and organisational support)

Spectrum of interventions e.g. smoking cessation

Using smoking cessation as an example and going from the individual to the population level, health promotion action can range from ‘brief interventions’ and advice to community based health promotion and social marketing (media etc.) to policy and legislation such as smoke free areas and access to purchasing

.

Working in PartnershipsWorking together toward shared objectives

Networking • exchange of information, updates and meetingsCoordinating • exchange information and change activities fro a

common purpose eg meet and agree to lobby for better youth services

Cooperating • exchange info, change activities and share

resources. Involves more time and high level of trust eg pool resources to run a health week to address an issue

Collaborating • all of the above, plus build the capacity of the other

partner for mutual benefit and common purpose eg provide funds, staff, facility or other resources

(source VicHealth MH Promotion short course)

The Swedish Public Health Policy

Historical background to the Swedish Public Health policy

A good system for vital statistics since 1750

From 1800 construction of community health services

A long tradition of popular struggle against the negative health effects of alcohol

The concern for the health of mothers and children was an important part of the welfare policy in the 1930’s and further on

Universal health insurance. Regional councils responsible for health services

A strong political commitment to healthGunnar Ågren 2005

A background to present public health work

Health has been an important part of social welfare

On the other hand no comprehensive public health policy

The medical perspective on public health has been very dominating especially after World War II

No strong emphasis on prevention with exception for injury prevention and occupational health

Primary care not very well developed

Gunnar Ågren 2005

Factors promoting a new public health policy

Increasing costs for health care – a disproportionate amount to highly specialized hospital care. Need for more preventive in health services

HIV/AIDS illustrated the need for a comprehensive preventive strategy

Increasing concern about inequity in health

A strategy group on public health in the government administration was formed in 1987

National Institute of Public Health founded 1992

Gunnar Ågren 2004

Average lifespan in Sweden 1751-2000

0

20

40

60

80

100

Females

Males

VaccinationAlcohol Sanitation

Rationing of alcohol

Ended 1955

National Public Health CommitteeIn 1997 a national public health committee was formed

All main political parties were represented, a number of experts

Many important NGO’s were represented

Main task: to propose public health goals and strategies

The committee worked for three years, a number of interim reports was delivered

The task of the committee – to propose national public health goals which should guide all sectors of the society

The goals were approved by the parliament in a revised version 2003.

Gunnar Ågren 2005

Gunnar Ågren 2005 60

Swedish public health policy- main target

areas 1. Participation and influence in the society

2. Economic and social security

3. Secure and favorable conditions during childhood and adolescence

4. Healthier working life

5. Healthy and safe environments and products

6. Health and medical care that more actively promotes good health

7. Effective protection against communicable diseases

8. Safe sexuality and good reproductive health

9. Increased physical activity

10. Good eating habits and safe food

11. Reduced use of tobacco and alcohol, a society free from illicit drugs and doping and a reduction in the harmful effects of excessive gambling.

To express the goals in relation to health determinants was an important decision

There is an obvious relation between the goals and political actions in order to achieve them

The main area of public health work becomes placed outside the health and medical sector

If the goals are broadly accepted they will guide actions in many sectors of the society

Gunnar Ågren 2005

Some problems

In some instances it may be hard to show that the fulfilment of a goal leads to improved health.

Economists, administrators and others may have difficulties in accepting population health as a desirable political goal

Conclusion – you have to provide good scientific evidence in order to promote public health policy

Gunnar Ågren 2005

A new role for NIPH

• Monitor the public health policy• Centre of excellence in the field of

methods in public health policy• Supervision of legislation concerning

alcohol, tobacco and illicit drugs• Support to regions and municipalities• Specific programmes concerning HIV and

gambling depency

How has the public health policy been implemented?

The main objectives have been approved by the parliament which gives them a strong political support

Indicators for all main objectives have been decided by the National Institute of Public Health after negotiations with other governmental agencies

18 agencies at national level are instructed by the government to participate in the public health policy

8 regions have been instructed to integrate public health into regional development plans

More than 50% of the 290 Swedish municipalities have adopted public health programs

Gunnar Ågren 2005

A public health policy report will be delivered to the government 2005• The report will be based on the 38

main indicators and further indicators in specific areas

• There will be a report on how the policy have been implemented and what actions have been taken

• The report will evaluate the policy and discuss prioritizations and revisions

Gunnar Ågren 2005

1. Participation and influence in the society

• Lack of participation and influence harmful for Public Health

• Solid scientific evidence for the causal relation between high demands-low control and disease

• Support for local participation, culture, ethnic integration part of the public health policy

2. Economic and social security• Loss of security causes economic

stress• Lack of employment and lack of

access to social services bad for health

• The poverty trap: Poverty > disease > lower incomes and higher expenditures > increased poverty

• Social welfare and equality is good for Public Health

Percent employed 20-64 year old

65

70

75

80

85

90

1970 1975 1980 1985 1990 1995 2000

Year

Per

cen

t Declining employment rate

3. Secure and favorable conditions during childhood and adolescence

• Childhood conditions important for health later in life

• Support and education to parents, good child care, health schools

• Comprehensive maternity care has been very important for the low infant mortality in Sweden

• Declining mental health among young people a major problem

4. Healthier working life• Taking good care of the

workforce an important factor for social and economic developement

• Stress at work-places and lack of influence important problems

• Worse working conditions for females

• Large increase in work related health problems

5. Healthy and safe environments and products

• Integrate environmental policy with public health work

• Noise and air pollution the most important problems from a health perspective in Sweden

• Global warming, air pollution – especially indoor, access to fresh water

• Injury protection is very effective also in economic terms

• Cooperation against the great global health risks

6. Health and medical care that more actively promotes good health

• A well developed and accessible primary care important for prevention

• Maternity and child care of particular importance

• Integration of medical and social services

• Health promotion and disease prevention important for the entire health sector.

Main problems from a public health perspective

• Reduced accessability due to high fees• Increasing costs for drugs• Difficult to control total costs in a market

system with a lot of providers• Difficult to introduce prevention• Lack of cooperation with other sectors in

society especially in rehabilitation

7. Effective protection against communicable diseases

• HIV/AIDS, Malaria och TBC important threats to the entire population and work-force i many countries

• Most new cases of HIV are infected outside Sweden

• International cooperation is in the self-interest of all countries

8. Safe sexuality and good reproductive health

• Unsafe sex the second most important health risk in developing countries

• Sexually transmitted disease increasing

• Trafficing an important health risk

9.Increased physical activity

• Sedentary life-style and lack of healthful physical activity a major health risk

• Main determinant of Cardiavascular disease, diabetes, osteoporosis, cancer

• Promotion of physical activity in schools and workplaces an important public health measure

10.Good eating habits and safe food

• Today approximately 1 billion people suffer from malnutrition

• Approximately the same number are overweight which is a major cause of premature mortality

• A unequal distribution of food is a major problem in all parts of the world

• To much fat and sugar and to little fruit and vegetables the main problem

11. Reduced use of tobacco and alcohol, a society free from illicit drugs and doping and a reduction in the harmful effects of excessive gambling

• Tobacco the first and alcohol the third determinant of global burden of disease

• The average taxation on alcohol beverages has decreased internationally

• The Swedish alcohol consumption of alcohol has increased

• Tobacco-related mortality increasing internationally but decreasing in Sweden

• Distribution of illicit drugs an organised market connected with international crime. Sweden has a restrictive policy on illicit drugs

Källa: Undersökningen av levnadsförhållanden, SCB

1980 1985 1990 1995 20000

10

20

30

40

Andel dagligrökare

Män

Kvinnor

Percentage of daily smokers, 16-84 years, 1980-2002

Males

Females

June 1st 2005 – smoking will be prohibited in restaurants

Gunnar Ågren 2005 80

The main tasks of the Swedish National Institute of Public Health

National centre of competence in the field of public healthFollow-up of the effects of the national public health policySupervision of the legislation concerning alcohol, tobacco and narcotics Advisory functions to the governmentCooperation with research funding agencies and support to coordination of public health researchStrategic support to politicians and professionals at regional and local levels, who have the main responsibility for public health workation and support to professionals at regional and local levels

Which are the main Swedish public health problems?

1. The increase in work-related health problems and absence from work

2. The increase in mental health problems, especially among young people

3. The increase in obesity and sedentary life-style

4. The increasing alcohol consumption

Possible actions

• Better working environment• Stricter rules for certification of sick leave• Better occupational health services• Lower benefits during sick-leave• Create jobs for people with decreased

working capacity

The Swedish alcohol consumptionLitres 100% alcohol/inhabitant

1990 1993 1995 1996 1998 2000 2001 20025

6

7

8

9

10

Sweden entered EU

Possible actions

• Restriction on sales and drinking in restaurants

• Education• Harder rules against drinking and driving• Information

Percentage of the Swedish population reporting insomnia

Sales of antidepressant drugs in Sweden

0

50

100

150

200

250

Mil

lio

ns

of

dai

ly d

ose

s

Possible actions

• Support to parents of small children• Better maternity and child care• Health promoting schools• Increase work opportunities for young

people• Decrease negative stress in work places

and schools

Källa: Undersökningen av levnadsförhållanden, SCB

BMI, males and females 16-74 years,1980-2002

1980 1989 1998 200123

23,5

24

24,5

25

25,5

26

Medel-BMI

Män

Kvinnor

Possible actions

• Decrease the intake of fat and sugar. Increase fruit and vegetables.- Pricing?

• Increase physical activity at least 30 minutes a day (60 minutes for young people)

• Prescriptions of physical activity and better food habits by doctors

• Physical activity in schools and work places.• Restrictions on food advertisments in TV to

children

Final conclusions

• The Swedish public health is still good in an international scale

• However, considerable health gaps• Mental health and self-reported health decreasing,

especially among young people• A number of threats against the health• A national public health policy is important to fight those

threats• International co-operation important in the field of public

health